<!--
 * Copyright TLR Team, Inc. All Rights Reserved.
-->
<div class="tlr-assessment-container">
    <form class="form-horizontal">
        <div class="form-group">
            <div class="col-sm-12 tlr-split-line">
                <label class="col-sm-2 control-label">7.用药</label>
            </div>
        </div>
        <div class="form-group">
            <div class="col-sm-12 tlr-split-line">
                <div style="display: block; padding: 10px;">
                    本次医药评估的表格包括：风险评估、药物列表、家庭治疗记录和用药许可。
                </div>
            </div>
        </div>
        <div class="form-group">
            <div class="col-sm-12 tlr-split-line">
                <div style="display: block; padding: 10px;">
                    风险评估
                </div>
            </div>
        </div>
        <div class="form-group">
            <div class="col-sm-12 tlr-split-line">
                <div style="display: block; padding: 10px;">
                    第一部分 意识能力
                </div>
            </div>
        </div>
        <div class="form-group">
            <div class="form-group">
                <div class="col-sm-12">
                    <div style="display: block; padding-left: 20px; font-size: 16px;">
                        需求评估中以下哪一条
                    </div>
                </div>
            </div>
        </div>
        <div class="tlr-form-layout">
            <div class="form-group">
                <label for="exampleInputEmail1">评估对象是否存在决策障碍？</label>
                <div class="radio">
                    <label>
                        <input type="radio" name="optionsRadios" id="optionsRadios1" value="1" ng-model="assessment.medication.risk.lackcapacity">是
                    </label>
                </div>
                <div class="radio">
                    <label>
                        <input type="radio" name="optionsRadios" id="optionsRadios2" value="0" ng-model="assessment.medication.risk.lackcapacity">否
                    </label>
                </div>
            </div>
            <div class="form-group">
                <label for="exampleInputEmail1">代表评估对象做出的决策是否符合其最佳利益？</label>
                <div class="radio">
                    <label>
                        <input type="radio" name="optionsRadios7_2" id="optionsRadios1" value="1" ng-model="assessment.medication.risk.bestinterestdecisions">是
                    </label>
                </div>
                <div class="radio">
                    <label>
                        <input type="radio" name="optionsRadios7_2" id="optionsRadios2" value="0" ng-model="assessment.medication.risk.bestinterestdecisions">否
                    </label>
                </div>
            </div>
            <div class="form-group">
                <label for="exampleInputEmail1">评估对象是否没有能力对护理和支持服务给予同意？</label>
                <div class="radio">
                    <label>
                        <input type="radio" name="optionsRadios7_3" id="optionsRadios1" value="1" ng-model="assessment.medication.risk.nogiven">是
                    </label>
                </div>
                <div class="radio">
                    <label>
                        <input type="radio" name="optionsRadios7_3" id="optionsRadios2" value="0" ng-model="assessment.medication.risk.nogiven">否
                    </label>
                </div>
            </div>
        </div>
        <div class="form-group">
            <div class="col-sm-12 tlr-split-line">
                <div style="display: block; padding-left: 20px;">
                    若以上任何一项选择为“是”，请向主管经理进一步咨询建议。若未“否”，请完成表格剩余部分
                </div>
            </div>
        </div>
        <div class="form-group">
            <div class="col-sm-12 tlr-split-line">
                <div style="display: block; padding: 10px;">
                    第二部分 健康
                </div>
            </div>
        </div>
        <div class="tlr-form-layout">
            <div class="form-group">
                <label for="exampleInputEmail1">评估对象是否患有视觉障碍？</label>
                <div class="radio">
                    <label>
                        <input type="radio" name="optionsRadios7_4" id="optionsRadios1" value="1"  ng-model="assessment.medication.risk.visualimpairment">是
                    </label>
                </div>
                <div class="radio">
                    <label>
                        <input type="radio" name="optionsRadios7_4" id="optionsRadios2" value="0" ng-model="assessment.medication.risk.visualimpairment">否
                    </label>
                </div>
            </div>
            <div class="form-group">
                <label for="exampleInputEmail1">评估对象是否患有任何一种会妨碍他们阅读药物说明的症状？</label>
                <div class="radio">
                    <label>
                        <input type="radio" name="optionsRadios7_5" id="optionsRadios1" value="1" ng-model="assessment.medication.risk.inhibitread">是
                    </label>
                </div>
                <div class="radio">
                    <label>
                        <input type="radio" name="optionsRadios7_5" id="optionsRadios2" value="0" ng-model="assessment.medication.risk.inhibitread">否
                    </label>
                </div>
            </div>
            <div class="form-group">
                <label for="exampleInputEmail1">评估对象是否存在任何已知的过敏或药物副作用？</label>
                <div class="radio">
                    <label>
                        <input type="radio" name="optionsRadios7_6" id="optionsRadios1" value="1" ng-model="assessment.medication.risk.allergie">是
                    </label>
                </div>
                <div class="radio">
                    <label>
                        <input type="radio" name="optionsRadios7_6" id="optionsRadios2" value="0" ng-model="assessment.medication.risk.allergie">否
                    </label>
                </div>
            </div>
            <div class="form-group">
                <label for="exampleInputEmail1" style="font-size: 16px;">如果有，请详述</label>
                <textarea class="form-control" rows="5" ng-model="assessment.medication.risk.allergiedetail"></textarea>
            </div>
        </div>
        <div class="form-group">
            <div class="col-sm-12 tlr-split-line">
                <div style="display: block; padding: 10px;">
                    第三部分  药物反应
                </div>
            </div>
        </div>
        <div class="tlr-table-layout">
            <table class="table table-bordered" style="font-size: 16px;">
                <thead>
                    <tr>
                        <th>潜在危害</th>
                        <th>风险</th>
                        <th>控制措施</th>
                    </tr>
                </thead>
                <tbody>
                    <tr>
                        <td>评估对象是否明确服务哪一种药物及何时服用药物?</td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.risk.drugReaction.potentialHazard[0].risk"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.risk.drugReaction.potentialHazard[0].control"></td>

                    </tr>
                    <tr>
                        <td>评估对象是否明确各药物功效?</td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.risk.drugReaction.potentialHazard[1].risk"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.risk.drugReaction.potentialHazard[1].control"></td>
                    </tr>
                    <tr>
                        <td>评估对象是否明确所有药物存放地点？</td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.risk.drugReaction.potentialHazard[2].risk"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.risk.drugReaction.potentialHazard[2].control"></td>
                    </tr>
                    <tr>
                        <td>是否需要隐蔽保存？（仅限居家养老）</td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.risk.drugReaction.potentialHazard[3].risk"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.risk.drugReaction.potentialHazard[3].control"></td>
                    </tr>
                    <tr>
                        <td>评估对象是够有能力倒出液态药剂？</td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.risk.drugReaction.potentialHazard[4].risk"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.risk.drugReaction.potentialHazard[4].control"></td>
                    </tr>
                    <tr>
                        <td>评估对象是否有能力从药瓶或药板中取药？</td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.risk.drugReaction.potentialHazard[5].risk"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.risk.drugReaction.potentialHazard[5].control"></td>
                    </tr>
                    <tr>
                        <td>若使用辅助药物，药物是否由健康专家/药剂师配补？</td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.risk.drugReaction.potentialHazard[6].risk"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.risk.drugReaction.potentialHazard[6].control"></td>
                    </tr>
                    <tr>
                        <td>评估对象是否能够按时获得药物？</td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.risk.drugReaction.potentialHazard[7].risk"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.risk.drugReaction.potentialHazard[7].control"></td>
                    </tr>
                    <tr>
                        <td>如果不能，该对象是否正在使用重复抓药体系？</td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.risk.drugReaction.potentialHazard[8].risk"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.risk.drugReaction.potentialHazard[8].control"></td>
                    </tr>
                    <tr>
                        <td>如使用眼药水，评估对象是否清楚药水存放位置？</td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.risk.drugReaction.potentialHazard[9].risk"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.risk.drugReaction.potentialHazard[9].control"></td>
                    </tr>
                    <tr>
                        <td>评估对象是否使用家庭治疗？</td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.risk.drugReaction.potentialHazard[10].risk"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.risk.drugReaction.potentialHazard[10].control"></td>
                    </tr>
                    <tr>
                        <td>药物是否为“按需服用”（之前为PRN）？</td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.risk.drugReaction.potentialHazard[11].risk"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.risk.drugReaction.potentialHazard[11].control"></td>
                    </tr>
                    <tr>
                        <td>如需使用药膏，评估对象是否能够独立敷用？</td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.risk.drugReaction.potentialHazard[12].risk"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.risk.drugReaction.potentialHazard[12].control"></td>
                    </tr>
                    <tr>
                        <td>评估对象是否能够独立使用喷雾器/雾化器？</td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.risk.drugReaction.potentialHazard[13].risk"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.risk.drugReaction.potentialHazard[13].control"></td>
                    </tr>

                </tbody>
            </table>
        </div>
        <div class="tlr-table-layout">
            <table class="table" style="padding: 15px;font-size: 16px;">
                <tbody>
                    <tr>
                        <td>
                            <div class="form-group">
                                <label>评估对象是否使用:</label>
                            </div>
                            <div class="form-group">
                                <div class="checkbox">
                                    <label>
                                        <input type="checkbox" ng-model="assessment.medication.risk.drugReaction.userUsed0">插管
                                    </label>
                                </div>
                                <div class="checkbox">
                                    <label>
                                        <input type="checkbox" ng-model="assessment.medication.risk.drugReaction.userUsed1">造口
                                    </label>
                                </div>
                                <div class="checkbox">
                                    <label>
                                        <input type="checkbox" ng-model="assessment.medication.risk.drugReaction.userUsed2">回肠造口术
                                    </label>
                                </div>
                            </div>
                        </td>
                        <td>
                            <div class="form-group">
                                <label>参与人员:</label>
                            </div>
                            <div class="form-group">
                                <div class="checkbox">
                                    <label>
                                        <input type="checkbox" ng-model="assessment.medication.risk.drugReaction.involved0">护士
                                    </label>
                                </div>
                                <div class="checkbox">
                                    <label>
                                        <input type="checkbox" ng-model="assessment.medication.risk.drugReaction.involved1">家属
                                    </label>
                                </div>
                                <div class="checkbox">
                                    <label>
                                        <input type="checkbox" ng-model="assessment.medication.risk.drugReaction.involved2">护理人员
                                    </label>
                                </div>
                            </div>
                        </td>
                    </tr>
                </tbody>
            </table>
        </div>
        <div class="tlr-table-layout">
            <table  class="table">
                <tbody>
                    <tr>
                        <td>
                            <div class="form-group">
                                <label for="exampleInputEmail1">医药评估等级(若鉴定为三级，请上报主管经理，进一步与多机构合作伙伴商讨):</label>

                                <div class="radio">
                                    <label>
                                        <input type="radio" name="optionsRadios7" id="optionsRadios" value="0"  ng-model="assessment.medication.risk.drugReaction.assessmentLevel">一级——独立用药
                                    </label>
                                </div>
                                <div class="radio">
                                    <label>
                                        <input type="radio" name="optionsRadios7" id="optionsRadios" value="1"  ng-model="assessment.medication.risk.drugReaction.assessmentLevel">二级——管理用药
                                    </label>
                                </div>
                                <div class="radio">
                                    <label>
                                        <input type="radio" name="optionsRadios7" id="optionsRadios" value="2"  ng-model="assessment.medication.risk.drugReaction.assessmentLevel">三级——专业技术
                                    </label>
                                </div>
                            </div>
                        </td>
                    </tr>
            </table>
        </div>
        <div class="form-group">
            <div class="col-sm-12 tlr-split-line"></div>
        </div>
        <div class="form-group">
            <label for="exampleInputEmail1" style="padding-left: 30px;font-size: 16px;">用药：药物列表</label>
        </div>
        <div class="tlr-form-layout">
            <div class="form-group">
                <label class="col-sm-2 control-label">客户姓名:</label>
                <div class="col-sm-9">
                    <input type="text" class="form-control" ng-model="assessment.medication.medicationList.name">
                </div>
            </div>
            <div class="form-group">
                <label class="col-sm-2 control-label">日期:</label>
                <div class="col-sm-9">
                    <p class="input-group">
                        <input id="medication_date_id" ng-model="assessment.medication.medicationList.date" placeholder="yyyy-mm-dd" style="height: 34px;" class="form-control" type="text">
                        <span class="input-group-addon"><span class="glyphicon glyphicon-calendar"></span></span>
                        <script type="text/javascript">
                            $("#medication_date_id").datetimepicker({
                                language: "zh-CN",
                                format: "yyyy-mm-dd",
                                minView: 2,
                                autoclose: true,
                                todayBtn: true,
                                pickerPosition: "bottom-left"
                            });
                        </script>
                    </p>
                </div>
            </div>
        </div>
        <div class="tlr-table-layout">
            <table class="table table-bordered" style="font-size: 16px;">
                <thead>
                    <tr>
                        <th>药物名称</th>
                        <th>剂量</th>
                        <th>禁忌</th>
                    </tr>
                </thead>
                <tbody>
                    <tr>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.medicationList.lstdata[0].name"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.medicationList.lstdata[0].dose"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.medicationList.lstdata[0].contraindication"></td>
                    </tr>
                    <tr>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.medicationList.lstdata[1].name"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.medicationList.lstdata[1].dose"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.medicationList.lstdata[1].contraindication"></td>
                    </tr>
                    <tr>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.medicationList.lstdata[2].name"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.medicationList.lstdata[2].dose"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.medicationList.lstdata[2].contraindication"></td>
                    </tr>
                    <tr>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.medicationList.lstdata[3].name"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.medicationList.lstdata[3].dose"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.medicationList.lstdata[3].contraindication"></td>
                    </tr>
                    <tr>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.medicationList.lstdata[4].name"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.medicationList.lstdata[4].dose"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.medicationList.lstdata[4].contraindication"></td>
                    </tr>
                </tbody>
            </table>
        </div>
        <div class="form-group">
            <div class="col-sm-12 tlr-split-line">
                <div style="display: block;">
                    药物列表必须定时更新、审查<br>注意：板装药物需连续四周每周进行药物有效期检查.
                </div>
            </div>
        </div>
        <div class="form-group">
            <label for="exampleInputEmail1" style="padding-left: 20px;font-size: 16px;">用药：家庭治疗记录</label>
        </div>
        <div class="tlr-form-layout">
            <div class="form-group">
                <label class="col-sm-2 control-label">客户姓名:</label>
                <div class="col-sm-9">
                    <input type="text" class="form-control" ng-model="assessment.medication.homeRemedyRecord.service_name">
                </div>
            </div>
            <div class="form-group">
                <label class="col-sm-2 control-label">过敏项目</label>
                <div class="col-sm-9">
                    <input type="text" class="form-control" ng-model="assessment.medication.homeRemedyRecord.allergies_item">
                </div>
            </div>
            <div class="form-group">
                <label class="col-sm-9">用药或治疗后最多72小时后，可联络该对象的全科医生做进一步咨询</label>
            </div>
        </div>
        <div class="tlr-table-layout">
            <table class="table table-bordered" style="font-size: 16px;">
                <thead>
                    <tr>
                        <th>时间</th>
                        <th>姓名</th>
                        <th>用药</th>
                        <th>剂量</th>
                        <th>原因</th>

                    </tr>
                </thead>
                <tbody>
                    <tr>
                        <td>
                            <p class="input-group" style="width:220px;">
                                <input id="homeRemedyRecord_allergies_data_id_0" ng-model="assessment.medication.homeRemedyRecord.allergies_data[0].remedyTime" placeholder="yyyy-mm-dd hh:mm:ss" style="height: 34px;" class="form-control" type="text">
                                <span class="input-group-addon"><span class="glyphicon glyphicon-calendar"></span></span>
                                <script type="text/javascript">
                                    $("#homeRemedyRecord_allergies_data_id_0").datetimepicker({
                                        language: "zh-CN",
                                        format: "yyyy-mm-dd hh:mm:ss",
                                        minView: 0,
                                        autoclose: true,
                                        todayBtn: true,
                                        pickerPosition: "bottom-left"
                                    });
                                </script>
                            </p>
                        </td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.homeRemedyRecord.allergies_data[0].name"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.homeRemedyRecord.allergies_data[0].medication"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.homeRemedyRecord.allergies_data[0].dose"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.homeRemedyRecord.allergies_data[0].reason"></td>
                    </tr>
                    <tr>
                        <td>
                            <p class="input-group" style="width:220px;">
                                <input id="homeRemedyRecord_allergies_data_id_1" ng-model="assessment.medication.homeRemedyRecord.allergies_data[1].remedyTime" placeholder="yyyy-mm-dd hh:mm:ss" style="height: 34px;" class="form-control" type="text">
                                <span class="input-group-addon"><span class="glyphicon glyphicon-calendar"></span></span>
                                <script type="text/javascript">
                                    $("#homeRemedyRecord_allergies_data_id_1").datetimepicker({
                                        language: "zh-CN",
                                        format: "yyyy-mm-dd hh:mm:ss",
                                        minView: 0,
                                        autoclose: true,
                                        todayBtn: true,
                                        pickerPosition: "bottom-left"
                                    });
                                </script>
                            </p>
                        </td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.homeRemedyRecord.allergies_data[1].name"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.homeRemedyRecord.allergies_data[1].medication"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.homeRemedyRecord.allergies_data[1].dose"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.homeRemedyRecord.allergies_data[1].reason"></td>

                    </tr>
                    <tr>
                        <td>
                            <p class="input-group" style="width:220px;">
                                <input id="homeRemedyRecord_allergies_data_id_2" ng-model="assessment.medication.homeRemedyRecord.allergies_data[2].remedyTime" placeholder="yyyy-mm-dd hh:mm:ss" style="height: 34px;" class="form-control" type="text">
                                <span class="input-group-addon"><span class="glyphicon glyphicon-calendar"></span></span>
                                <script type="text/javascript">
                                    $("#homeRemedyRecord_allergies_data_id_2").datetimepicker({
                                        language: "zh-CN",
                                        format: "yyyy-mm-dd hh:mm:ss",
                                        minView: 0,
                                        autoclose: true,
                                        todayBtn: true,
                                        pickerPosition: "bottom-left"
                                    });
                                </script>
                            </p>
                        </td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.homeRemedyRecord.allergies_data[2].name"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.homeRemedyRecord.allergies_data[2].medication"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.homeRemedyRecord.allergies_data[2].dose"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.homeRemedyRecord.allergies_data[2].reason"></td>

                    </tr>
                    <tr>
                        <td>
                            <p class="input-group" style="width:220px;">
                                <input id="homeRemedyRecord_allergies_data_id_3" ng-model="assessment.medication.homeRemedyRecord.allergies_data[3].remedyTime" placeholder="yyyy-mm-dd hh:mm:ss" style="height: 34px;" class="form-control" type="text">
                                <span class="input-group-addon"><span class="glyphicon glyphicon-calendar"></span></span>
                                <script type="text/javascript">
                                    $("#homeRemedyRecord_allergies_data_id_3").datetimepicker({
                                        language: "zh-CN",
                                        format: "yyyy-mm-dd hh:mm:ss",
                                        minView: 0,
                                        autoclose: true,
                                        todayBtn: true,
                                        pickerPosition: "bottom-left"
                                    });
                                </script>
                            </p>
                        </td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.homeRemedyRecord.allergies_data[3].name"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.homeRemedyRecord.allergies_data[3].medication"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.homeRemedyRecord.allergies_data[3].dose"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.homeRemedyRecord.allergies_data[3].reason"></td>

                    </tr>
                    <tr>
                        <td>
                            <p class="input-group" style="width:220px;">
                                <input id="homeRemedyRecord_allergies_data_id_4" ng-model="assessment.medication.homeRemedyRecord.allergies_data[4].remedyTime" placeholder="yyyy-mm-dd hh:mm:ss" style="height: 34px;" class="form-control" type="text">
                                <span class="input-group-addon"><span class="glyphicon glyphicon-calendar"></span></span>
                                <script type="text/javascript">
                                    $("#homeRemedyRecord_allergies_data_id_4").datetimepicker({
                                        language: "zh-CN",
                                        format: "yyyy-mm-dd hh:mm:ss",
                                        minView: 0,
                                        autoclose: true,
                                        todayBtn: true,
                                        pickerPosition: "bottom-left"
                                    });
                                </script>
                            </p>
                        </td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.homeRemedyRecord.allergies_data[4].name"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.homeRemedyRecord.allergies_data[4].medication"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.homeRemedyRecord.allergies_data[4].dose"></td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.homeRemedyRecord.allergies_data[4].reason"></td>

                    </tr>

                </tbody>
            </table>
            <div class="form-group">
                <div class="col-sm-12 tlr-split-line">
                    <div style="display: block;">

                    </div>
                </div>
            </div>
        </div>
        <div class="form-group">
            <label for="exampleInputEmail1" style="padding-left: 20px;font-size: 16px;">用药：用药许可</label>
        </div>
        <div class="tlr-form-layout">
            <div class="form-group">
                <label class="col-sm-2 control-label">客户姓名:</label>
                <div class="col-sm-9">
                    <input type="text" class="form-control"  ng-model="assessment.medication.homeRemedyRecord.name">
                </div>
            </div>
        </div>
        <div style="display:block; padding-left: 10px;">
            <table  class="table" style="padding: 15px;font-size: 16px;">
                <tbody>
                    <tr>
                        <td>
                            <div class="form-group" style="padding-left: 10px;">
                                <label for="exampleInputEmail1">选择其中一选项</label>
                                <div class="radio">
                                    <label>
                                        <input type="radio" name="optionsRadios_last" id="optionsRadios1" value="1" ng-model="assessment.medication.homeRemedyRecord.option">我授权一位护理人员，按照家庭治疗/用药列表内容，协助我服用任何处方药或非处方药
                                    </label>
                                </div>
                                <div class="radio">
                                    <label>
                                        <input type="radio" name="optionsRadios_last" id="optionsRadios2" value="2" ng-model="assessment.medication.homeRemedyRecord.option">我授权一位护理人员，在家庭用药列表指导下，进行处方药用药，并协助我进行非处方药用药
                                    </label>
                                </div>
                                <div class="radio">
                                    <label>
                                        <input type="radio" name="optionsRadios_last" id="optionsRadios2" value="3" ng-model="assessment.medication.homeRemedyRecord.option">我无需协助进行用药。我可以独立用药或者我的家人/代表协助我用药
                                    </label>
                                </div>

                            </div>
                        </td>
                    </tr>
                </tbody>
            </table>
            <div class="form-group">
                <div class="col-sm-12 tlr-split-line">
                    <div style="display: block;">
                        我清楚了解上述各协助类型，且上述信息将在我个人的用药支持计划中详细陈述。我清楚了解我有权在任何时候拒绝上述协助。在此，我同意将上述信息记录在案
                    </div>
                </div>
            </div>
            <table class="table" style="padding: 15px;font-size: 16px;">
                <tbody>
                    <tr>
                        <td>客户签名:</td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.homeRemedyRecord.signature"></td>
                    </tr>
                    <tr>
                        <td>日期:</td>
                        <td> 
                            <p class="input-group" style="width:220px;">
                                <input id="medication_signdate_id" ng-model="assessment.medication.homeRemedyRecord.signdate" placeholder="yyyy-mm-dd" style="height: 34px;" class="form-control" type="text">
                                <span class="input-group-addon"><span class="glyphicon glyphicon-calendar"></span></span>
                                <script type="text/javascript">
                                    $("#medication_signdate_id").datetimepicker({
                                        language: "zh-CN",
                                        format: "yyyy-mm-dd",
                                        minView: 0,
                                        autoclose: true,
                                        todayBtn: true,
                                        pickerPosition: "bottom-left"
                                    });
                                </script>
                            </p>
                        </td>
                    </tr>
                    <tr>
                        <td width="150">评估人员姓名:</td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.homeRemedyRecord.assessor"></td>
                    </tr>
                    <tr>
                        <td width="150">日期:</td>
                        <td> 
                            <p class="input-group" style="width:220px;">
                                <input id="medication_hdate_id" ng-model="assessment.medication.homeRemedyRecord.date" placeholder="yyyy-mm-dd" style="height: 34px;" class="form-control" type="text">
                                <span class="input-group-addon"><span class="glyphicon glyphicon-calendar"></span></span>
                                <script type="text/javascript">
                                    $("#medication_hdate_id").datetimepicker({
                                        language: "zh-CN",
                                        format: "yyyy-mm-dd",
                                        minView: 0,
                                        autoclose: true,
                                        todayBtn: true,
                                        pickerPosition: "bottom-left"
                                    });
                                </script>
                            </p>
                        </td>
                    </tr>
                </tbody>
            </table>
            <div class="form-group">
                <div class="col-sm-12 tlr-split-line">
                    <div style="display: block;">
                        评估对象经评估认定不具备做出此授权的能力，因此其代表已经授权在“最佳利益”原则知道下为其做出决策：
                    </div>
                </div>
            </div>
            <table  class="table" style="padding: 15px;font-size: 16px;">
                <tbody>
                    <tr>
                        <td width="150">代表姓名</td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.homeRemedyRecord.agentsign"></td>
                    </tr>
                    <tr>
                        <td width="150">日期:</td>
                        <td> 
                            <p class="input-group" style="width:220px;">
                                <input id="medication_agentsigndate_id" ng-model="assessment.medication.homeRemedyRecord.agentsigndate" placeholder="yyyy-mm-dd" style="height: 34px;" class="form-control" type="text">
                                <span class="input-group-addon"><span class="glyphicon glyphicon-calendar"></span></span>
                                <script type="text/javascript">
                                    $("#medication_agentsigndate_id").datetimepicker({
                                        language: "zh-CN",
                                        format: "yyyy-mm-dd",
                                        minView: 0,
                                        autoclose: true,
                                        todayBtn: true,
                                        pickerPosition: "top-left"
                                    });
                                </script>
                            </p>
                        </td>
                    </tr>
                    <tr>
                        <td width="150">与评估对象关系:</td>
                        <td> <input type="text" class="form-control input-sm tlr-table-editbox" ng-model="assessment.medication.homeRemedyRecord.relationship"></td>
                    </tr>
                </tbody>
            </table>
        </div>
        <div class="form-group">
            <div class="col-sm-9">
                <input class="btn btn-default" style="float: right;" type="button" value="下一页" ng-click="nextPage(8)">
                <input class="btn btn-default" style="float: right; margin-right: 30px;" type="button" value="上一页" ng-click="prevPage(6)">
            </div>
        </div>
    </form>
</div>

